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Visual-Perceptual Deficits
& Treatment Strategies Post TBI
Part 1
Patricia McGee, MS, OTR/L
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Learning Objectives 1. Understand the physiology of visual-
perception. 2. Recognize the signs & symptoms of common visual-perceptual deficits post TBI.
3. Understand the screening & treatment strategies for common visual-perceptual deficits post TBI.
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Prevalence
• TBI is one of the major causes of death and disability in the U.S (CDC, 2017)
• 90% of TBI patients have visual-perceptual
dysfunction (Jacobson & Marcus, 2011)
• Veterans: 50% of those dx with TBI
reported visual complaints (Radomski et al., 2014)
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Why is visual-perception so important?
70% of all sensory processing in the cerebral cortex is directly affected by information
coming from the 2 eyes (Hulse & Dudley, 2010)
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As a result….
An injury to the brain WILL have an impact on the visual system regardless of where the legion exists in the brain
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Vision TRUMPS all other senses! We need our vision to integrate
with our other senses for normal sensorimotor integration.
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Why is visual-perception so important?
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Did you know?
• Deficits are not always recognized because:
• Patients fail to articulate complaints • Labeled as confused, clumsy, anxious
uncooperative, or unmotivated • Clinicians unaware that vision deficits may be
the cause of the patient’s behavior • Lack of standardized vision screen for TBI • Novice clinicians
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So where do we start?
1. Basic (really basic) review of anatomy & physiology of the visual system
2. Recognizing common symptoms / deficits 3. Visual – perceptual screening 4. Treatment strategies
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Vision vs. Perception
Vision • Defined as the deriving
of meaning and directing of action as triggered by light
• Visual acuity • Visual attention • Visual field • Ocular alignment • Oculomotor control • Convergence • Accommodation
Perception • Active processing of
sensory input that interacts with higher level processing to interpret the environment
• It’s an aspect of cognition • Visual Neglect • Depth perception • Body part ID • R/L discrimination • Midline orientation • Visual agnosia • Color discrimination • Spatial relations
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Vision & Perception How does it work?
A very basic review…. 1. Light passes through the cornea & lens 2. Combine to produce a clear image of the visual world on the retina - a sheet of photoreceptors 3. The image on the retina is reversed: objects above the center project to the lower part and vice versa
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Vision & Perception How does it work?
4. Electrical signals from the retina are sent via the optic nerve to the geniculate nucleus to the primary visual cortex which:
• Processes visual information allowing us to see • Located in occipital lobe
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Common Visual-Perceptual Symptoms & Deficits
Post TBI
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Post Traumatic Vision Syndrome (PTVS)
Is a dysfunction in peripheral/ambient visual processing
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Most Common Deficits Post TBI • Visual acuity deficits • Binocular vision dysfunction
• Strabismus • Convergence insufficiency • Accommodation dysfunction • Impaired stereopsis
• Visual field deficits and neglect • Oculomotor dysfunction
• Nystagmus • Visual Midline Shift Syndrome • Photosensitivity
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Visual Acuity Deficits
Clarity and sharpness of vision
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Binocular Vision Dysfunction: Strabismus
• Eyes are not aligned when viewing an object • Intermittent or constant • Caused by muscle imbalance • Exotropia most common • Results in loss of depth perception • Could lead to blindness in affected eye
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Binocular Vision Dysfunction: Convergence Insufficiency
Adduction of eyes to view an object at near
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Binocular Vision Dysfunction: Convergence Insufficiency
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Binocular Vision Dysfunction: Convergence Insufficiencies
• Can lead to suppression of one eye
• Covers one eye to limit blurring/double vision • Brain begins to ignore one eye/shuts down • Limits complaints, hard to distinguish • Results in loss of binocular vision and depth
perception
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Binocular Vision Dysfunction:
Accommodation
Insufficiency
Inability to focus as object moves closer
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Binocular Vision Dysfunction: Impaired Stereopsis
Depth Perception
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Binocular Vision Dysfunction Symptoms
• Eyestrain • Headaches • Blurred vision • Double vision • Inability to
concentrate • Short attention span • Incoordination • Decreased depth
perception • Decreased eye
contact
• Squinting, rubbing, closing or covering an eye
• Frequent loss of place • Trouble remembering what
was read • Sleepiness during the
activity • Motion sickness or vertigo • Poor posture
• When completing tasks requiring near vision
• Head tilt
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Binocular Vision Dysfunction Functional Implications
• Trouble catching balls and other objects thrown in the air • Avoidance of games that involve depth perception • Frequency mishaps due to misjudgment of physical
distance • Trips and stumbles uneven surfaces • Frequent spilling or knocking over of objects • Bumping into doors, furniture and other stationary
objects • Sports accidents • Car parking accidents
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Visual Field Deficits
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Visual Field Deficits
Homonymous Hemianopia Visual field “cut”
Visual Field Neglect Severe inattention
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Types of Hemianopia
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Visual Field Cut
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Visual Field Deficits Which is which?
Homonymous Hemianopia Visual Field “Cut”
• Typically aware of deficit
• Compensatory strategies are
effective
• Visual deficit only
• Postural alignment ok
Visual Field Neglect Severe Inattention
• Lack of deficit awareness
• Compensatory strategies are
tough to comprehend
• Multi-sensory deficit
• Posture misaligned
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Oculomotor Dysfunction: Nystagmus
• Repetitive, uncontrolled movements
• Results in reduced vision &
depth perception • Impacts balance and
coordination • Can occur from side to side, up
and down, or in a circular pattern
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Visual Midline Shift Syndrome
• Perception of midline is off to the side
• Symptoms
• Floor may appear tilted • Walls and/or floor
appear to shift or move • Veering during mobility • Leans away from the
affected side • Imbalance • Disorientation • Vertigo
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Photosensitivity • Called photophobia
• An elevated sensitivity to light in the absence of ocular inflammation or infection
• Generalized to all types of lighting or selective to
fluorescent lighting • Symptoms
• fatigue with higher level cognitive tasks, including multi-tasking • fatigue with physical activity • Eye strain / fatigue • Headache or migraine • Malaise / nausea • Disequilibrium, dizziness, and possible vertigo • Increased sensitivity to motion of visual stimuli (scrolling text, crowded streets, etc. )